Privilege Request Form Emergency Medicine
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1 Privilege Request Form SECTION I GENERAL REQUIREMENTS EMERGENCY MEDICINE Requested Staff Category Active Courtesy Consulting Affiliate Basic Education: MD or DO INITIAL APPOINTMENT Minimal formal training and experience: Successful completion of an ACGME or AOA accredited residency in Internal Medicine, Family Practice, General Surgery, Pediatric Medicine or. OR Member in good standing of an accredited acute care or surgical hospital and/or ambulatory surgery center, with the same or similar unrestricted privileges. The number of cases performed in the last 12 months for each procedure requested along with the documentation of proficiency must be sufficient to validate competence. An applicant who has just completed a residency shall provide his/her residency log. Additional documentation and monitoring may be required at the discretion of the Medical Director or the Chief of Staff. Some procedures may require additional documentation of training and experience which is acceptable to the Medical Director. Summaries for other institutions, written communication of documents from the Chairperson of the designee of an approved academic training program, approved continuing medical education course, or clinical department from another institution attesting to completion of a specified course of training, and/or the number of the specified successful procedures performed, and/or the applicants known ability to perform a specific procedure for which the applicant has previously been formally trained to carry out in an approved program. Must maintain continuous active certification in ACLS and PALS. 03/2013 Page 1 of 8 Privilege Request Form
2 Interview by the Medical Director and/or Chief of Staff when requested. REAPPOINTMENT MAINTENANCE OF PRIVILEGE Demonstrated evidence of clinical activity from relevant professional practice evaluation during the past 24 months without significant quality variations, OR Peer recommendations when performance data is insufficient at the time of reappraisal; and Ongoing maintenance of continuing medical education as it pertains to scope of license and specialty. SECTION II PRIVILEGES REQUESTED Basic Privileges Privileges to assess, evaluate, diagnose and provide initial treatment to patients of all ages who present in the emergency department with any symptom, illness, injury or condition. To provide services necessary to ameliorate minor illness or injuries and stabilize patients with major illnesses or injuries. To assess all patients to determine whether additional care is necessary and to facilitate an appropriate transfer of these patients. Provide consultation when requested for the management of patients of all ages who have been admitted to the hospital setting with accidental or purposeful poisoning through exposure to prescription and nonprescription medications, drugs of abuse, household or industrial toxins, and environmental toxins. Areas of medical toxicology include acute pediatric and adult drug ingestion; drug abuse; addiction and withdrawal; chemical poisoning exposure and toxicity; hazardous materials exposure and toxicity; and occupational exposure. Core Privileges Requested Granted Denied Admit Patients Scheduled Surgical Patients and Readmit previous surgical VMC patients Abdominal and Gastrointestinal Cardiovascular 03/2013 Page 2 of 8 Privilege Request Form
3 Core Privileges Requested Granted Denied Cutaneous Environmental Head and Neck Hematologic Immune System Musculoskeletal Nervous System Obstetrics & Gynecology Neonatology Pediatrics Renal Thoracic and Respiratory Toxicology and Pharmacology Traumatic Emergency Ultrasound OB(presence/absence of intrauterine fetus) Cardiac (beating heart/pericardial fluid) Trauma (FAST exam) Renal(presence of hydronephrosis) AAA Gallbladder (presence of stones) Ultrasound guided placement of Central Line Emergency thoracotomy (patients in cardiac arrest, in extremis, or impending cardiac arrest, for emergency access to the pericardium in suspected tamponade, internal cardiac message, cross-clamping of the aorta, or control of un controllable hemorrhage) Emergency tube thoracostomy Emergency reduction of dislocations: digits, shoulder, knee, ankle, hip Venous cutdown 03/2013 Page 3 of 8 Privilege Request Form
4 Core Privileges Requested Granted Denied Emergency cardioversion Emergency cricothyrotomy Rapid sequence intubation with pharmacologic agents Difficult airway adjuncts and fiberoptic laryngoscopy Initial ED mechanical ventilator management Central venous access; subclavian, internal jugular, femoral Intubation; endotracheal, nasotracheal, orogastric, nasogastric Laryngoscopy Paracentesis Diagnostic peritoneal lavage Lumbar puncture Arthrocentesis Emergency testicular detorsion Tonometry Compartment pressure measurement Slit lamp examination Thoracentesis Emergency vaginal delivery & perimortum c-section Emergency transvenous and transcultaneous temporary pacer Emergency pericardiocentesis I & D abcess, barholin s cyst Laceration repair Nail trephination FB removal; nose, ear, superficial subcutaneous, pharyngeal, vaginal, subungual, corneal, cunjuctival Emergency fracture care, splinting/immobilization Blood, fluid, and blood component administration Anoscopy/proctoscopy Intraosseous infusion Epistaxis control; anterior/posterior packing, balloon tamponade 03/2013 Page 4 of 8 Privilege Request Form
5 Core Privileges Requested Granted Denied EKG interpretation Surgical Procedures ABG sampling ACLS drug therapy Arterial Catheterization Bladder Catheterization Bladder, Foley insertion Control of epistaxis, nasal packing CPR Gastric lavage Insertion of temporary pacemaker Laryngoscopy Lumbar puncture Nasogastric tube insertion Orthopedic casting and splinting Slit lamp examination Suture techniques Thoracentesis Venipuncture Venous cut down Wound Management # Procedures in last 12 months Requested Granted Granted w Conditions Denied I have been approved for these procedures at the following hospitals/ambulatory surgery centers: 03/2013 Page 5 of 8 Privilege Request Form
6 SECTION III - ACKNOWLEDGE OF PRACTITIONER: I have requested only those specific privileges for which by education, training, current experience and demonstrated performance I am qualified to perform and for which I wish to exercise at the Hospital. I hereby attest that the references, reports, records and information are available that verify my qualifications and competency to practice as requested. I understand that: 1. In exercising any clinical privileges granted, I am constrained by any hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. 2. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws. 3. The use of any other new, untried, or unproven procedure/treatment modality/instrumentation maybe performed or used, only after the regular credentialing process has been completed and the privilege to perform or use said procedure/treatment modality/instrumentation has been granted to the individual practitioner PHYSICIAN SIGNATURE DATE 03/2013 Page 6 of 8 Privilege Request Form
7 SECTION IV RECOMMENDATIONS AND APPROVALS Recommendation of the Medical Director: I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and recommend the following action on the privileges: Approval of all requested privileges Approval of the following privileges with conditions: Denial of the following privileges: Medical Director Recommendation of the Medical Executive Committee: I have reviewed the requested clinical privileges and supporting documentation for the above named applicant and recommend the following action on the privileges: Approval of all requested privileges Approval of the following privileges with conditions: Denial of the following privileges: 03/2013 Page 7 of 8 Privilege Request Form
8 Chief of Staff Decision of the Governing Board: The Governing Board has reviewed the above recommendations regarding the requested clinical privileges and supporting documentation for the above named applicant and has: Granted all requested privileges Granted the following privileges with conditions: Denied the following privileges: Chairman of the Board 03/2013 Page 8 of 8 Privilege Request Form
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